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A 5 yo Male with PMH of Down’s Syndrome presents with AMS while jumping on his bed. Mother states that he was jumping and suddenly became limp. She denies any trauma, fevers, seizure activity, or any other recent medical complaints or illnesses. The patient is intubated. CT Brain shows ICH of the Left Frontal Lobe with 6 mm of Left to Right Midline shift. Pt is stable with normal BP. Which intervention is the most correct to perform next?

A. Paralyze the patient with vecuroniumB. Immediately hyperventilate the patient to a PaCO2 of 30C. Place the patient on a propofol dripD. Administer a Hypertonic Saline bolus with 3-5 ml/kg 3% NaCl.E. Administer a 0.6 mg/kg decadron bolus

​Certainly, a more in depth review will reveal a more complete understanding of the methodology, however, here are a few takeaways: First, a thorough history and physical is necessary in these cases. If my patient meets the definition of BRUE, they are in the low risk category and I find no worrisome characteristics on physical and history and can have follow up the next day, then I plan to discharge them. I would consider keeping the patient hooked up to a cardiorespiratory and pulse ox monitor during my evaluation and would consider getting an EKG, as there is a 4% incidence of cardiac disease found in ALTE patients in one study. Beyond those things, I would not do any more for my low risk BRUE patients. With this guideline in place, the hope is more specific research and studies can be done to further guide practitioners in dealing with BRUE patients.

A 14 year-old female walks into your ED with her parents. She has a wobbling gait with chorea-like movement of her extremities and her head, and her jaw protrudes to the left in a fixed position. You enter the room and after introductions, ask the patient what brought her in today. She is lying stiffly on the exam bed with her head still rigidly to left and you are able to discern a mumbled “I can’t move my jaw.” You turn to her parents and ask why they bought her in. They respond, “An hour ago, she became stiff and had difficulty talking so we came here.” When asked what medical problems she has, they report “she was diagnosed with a mood disorder three months ago and has been on these medications.” Mom pulls three medications out of her purse and hands them to you: Sertraline, Buspirone, and Aripiprazole. She notes that she just started the aripiprazole a few days ago. You ask the nurse to place an IV and give 50 mg of Benadryl.

While she is doing this, you complete a quick neurologic exam having already assessed her gait as she walked in. She responds appropriately to your questions but it is difficult to understand her. The patient is unable to move her jaw and neck but her cranial nerves are otherwise intact. Her eyes track but revert to the left upper quadrant when relaxed. Her jaw is stuck in a mid-open position. She has full range of motion of her extremities, but they appear stiff and slow in their movement. Her reflexes are 2/4 bilaterally in the upper and lower extremities. Sensation with 2-point discrimination is intact.

At this point, the nurse has placed an IV and given the Benadryl. Over the course of 45 seconds while you watch the clock, you see the patient’s jaw relax and head and eyes turn to midline. When asked how she is feeling, she clearly states “I feel amazing.” She then promptly falls asleep. Well done, doctor. Over the course of four minutes, you’ve correctly identified, diagnosed, and treated this patient’s Dystonic Reaction. After a period of observation, she was discharged with Benadryl 25mg Q6h for 48 hours and told to stop the aripiprazole after speaking to her psychiatrist.

Quick Review for Dystonic Reactions:

Classically caused by antipsychotics

50% of reactions occur within 48 hours and 90% with 5 days of starting a D-2 antagonist.

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